Factors associated with foot pain severity and foot-related disability in individuals with first metatarsophalangeal joint OA

Different fixation constructs and the risk of non-union following first metatarsophalangeal joint arthrodesis

BACKGROUND

The aim of this study was to determine if a single or separate construct with interfragmentary screw was associated with higher rates non-union following first metatarsophalangeal joint (MTPJ) arthrodesis.

METHODS

A retrospective analysis of patients undergoing first MTPJ arthrodesis between April 2010 and June 2017 was performed. Patients who received either a single (Stryker Anchorage 1 MTP Cross Plate) or separate (Stryker Anchorage 1 MTP locking plate with one Asnis partially threaded compression screw) construct locking plate and interfragmentary compression screw were reviewed. Descriptive statistics were generated for sample demographics and between-group differences were calculated. Multivariable regressions explored internal fixation type and association with non-union.

RESULTS

A total of 280 first MTPJ arthrodesis met the inclusion criteria and were reviewed. The incidence of non-union was 7.9% of procedures (22 joints). Following multivariable binary logistic regression, the single construct locking plate with interfragmentary compression screw was associated with an increased risk of non-union (OR 3.43, 95% CI 1.26-9.33), adjusting for age, gender and comorbidity.

CONCLUSIONS

A single construct interfragmentary screw and locking plate (Stryker Anchorage 1 MTP Cross Plate) was associated with an increased incidence of non-union following first MTPJ arthrodesis.

Foot and Leg Muscle Weakness in People With Midfoot Osteoarthritis

OBJECTIVE

To compare foot and leg muscle strength in people with symptomatic midfoot osteoarthritis (OA) with asymptomatic controls, and to determine the association between muscle strength, foot pain, and disability.

METHODS

Participants with symptomatic midfoot OA and asymptomatic controls were recruited for this cross-sectional study from general practices and community health clinics. The maximum isometric muscle strength of the ankle plantarflexors, dorsiflexors, invertors and evertors, and the hallux and lesser toe plantarflexors was measured using hand-held dynamometry. Self-reported foot pain and foot-related disability were assessed with the Manchester Foot Pain and Disability Index. Differences in muscle strength were compared between groups. Multivariable regression was used to determine the association between muscle strength, foot pain, and disability after adjusting for covariates.

RESULTS

People with midfoot OA (n = 52) exhibited strength deficits in all muscle groups, ranging from 19% (dorsiflexors) to 30% (invertors) relative to the control group (n = 36), with effect sizes of 0.6-1.1 (P < 0.001). In those with midfoot OA, ankle invertor muscle strength was negatively and independently associated with foot pain (β = -0.026 [95% confidence interval (95% CI) -0.051, -0.001]; P = 0.045). Invertor muscle strength was negatively associated with foot-related disability, although not after adjustment for depressive symptoms (β = -0.023 [95% CI -0.063, 0.017]; P = 0.250).

CONCLUSION

People with symptomatic midfoot OA demonstrate weakness in the foot and leg muscles compared to asymptomatic controls. Preliminary indications from this study suggest that strengthening of the foot and leg muscles may offer potential to reduce pain and improve function in people with midfoot OA.

Determination of Minimum Clinically Important Difference (MCID) in Visual Analog Scale (VAS) Pain and Foot and Ankle Ability Measure (FAAM) Scores After Hallux Valgus Surgery

BACKGROUND

Minimum clinically important difference (MCID) defines a threshold when determining clinically significant treatment improvement. Visual analog scale (VAS) and Foot and Ankle Ability Measure activities of daily living (FAAM-ADL) are commonly used for measuring hallux valgus correction. This study aimed to determine MCID in VAS pain and FAAM-ADL scores for hallux valgus correction and additionally, to identify variables influencing achievement of the VAS pain MCID.

METHODS

Patients undergoing hallux valgus surgery were retrospectively included. VAS pain, FAAM-ADL, and pain satisfaction surveys were collected preoperatively and minimum 1-year postoperatively. Using a 6-point Likert-type pain satisfaction scale, patients reporting low postoperative satisfaction scores 1 through 3 were categorized as "dissatisfied," and high satisfaction scores 4 through six as "satisfied." One distribution-based method and 2 anchor-based methods were used to calculate MCID. Further, a logistic regression was calculated to determine if one group (defined by sex, pain satisfaction, preoperative VAS pain, concomitant lesser toe deformity correction, and specific hallux valgus correction procedure) had a greater likelihood of achieving the VAS pain MCID threshold. This study included 170 patients with postoperative follow-up averaging 23.6 months.

RESULTS

Calculated MCID scores ranged from 1.8 to 5.2 points for VAS pain and 11.1 to 22.7 points for FAAM-ADL. Moderate deformity correction with proximal first metatarsal osteotomy (Ludloff) (OR=2.236, P = .036) or severe deformity correction with first tarsometatarsal arthrodesis (Lapidus) (OR=3.145, P = .046); and higher preoperative pain scores (OR=1.045, P < .010) had significantly higher odds of meeting VAS pain MCID.

CONCLUSION

This study demonstrated MCID values that may indicate significant pain and function improvement after hallux valgus correction. Higher preoperative pain, and utilization of proximal metatarsal osteotomy or first tarsometatarsal arthrodesis for moderate or severe deformity correction resulted in significantly greater likelihood of reaching the VAS pain MCID than utilizing distal metatarsal and/or proximal phalanx osteotomy for mild deformity treatment.

LEVEL OF EVIDENCE

Level IV, validating outcome measures.

Foot pain and foot health in an educated population of adults: results from the Glasgow Caledonian University Alumni Foot Health Survey

Background

Foot pain is common amongst the general population and impacts negatively on physical function and quality of life. Associations between personal health characteristics, lifestyle/behaviour factors and foot pain have been studied; however, the role of wider determinants of health on foot pain have received relatively little attention. Objectives of this study are i) to describe foot pain and foot health characteristics in an educated population of adults; ii) to explore associations between moderate-to-severe foot pain and a variety of factors including gender, age, medical conditions/co-morbidity/multi-morbidity, key indicators of general health, foot pathologies, and social determinants of health; and iii) to evaluate associations between moderate-to-severe foot pain and foot function, foot health and health-related quality-of-life.

Methods

Between February and March 2018, Glasgow Caledonian University Alumni with a working email address were invited to participate in the cross-sectional electronic survey (anonymously) by email via the Glasgow Caledonian University Alumni Office. The survey was constructed using the REDCap secure web online survey application and sought information on presence/absence of moderate-to-severe foot pain, patient characteristics (age, body mass index, socioeconomic status, occupation class, comorbidities, and foot pathologies). Prevalence data were expressed as absolute frequencies and percentages. Multivariate logistic and linear regressions were undertaken to identify associations 1) between independent variables and moderate-to-severe foot pain, and 2) between moderate-to-severe foot pain and foot function, foot health and health-related quality of life.

Results

Of 50,228 invitations distributed, there were 7707 unique views and 593 valid completions (median age [inter-quartile range] 42 [31–52], 67.3% female) of the survey (7.7% response rate). The sample was comprised predominantly of white Scottish/British (89.4%) working age adults (95%), the majority of whom were overweight or obese (57.9%), and in either full-time or part-time employment (82.5%) as professionals (72.5%). Over two-thirds (68.5%) of the sample were classified in the highest 6 deciles (most affluent) of social deprivation. Moderate-to-severe foot pain affected 236/593 respondents (39.8%). High body mass index, presence of bunions, back pain, rheumatoid arthritis, hip pain and lower occupation class were included in the final multivariate model and all were significantly and independently associated with moderate-to-severe foot pain (p < 0.05), except for rheumatoid arthritis (p = 0.057). Moderate-to-severe foot pain was significantly and independently associated lower foot function, foot health and health-related quality of life scores following adjustment for age, gender and body mass index (p < 0.05).

Conclusions

Moderate-to-severe foot pain was highly prevalent in a university-educated population and was independently associated with female gender, high body mass index, bunions, back pain, hip pain and lower occupational class. Presence of moderate-to-severe foot pain was associated with worse scores for foot function, foot health and health-related quality-of-life. Education attainment does not appear to be protective against moderate-to-severe foot pain.

Foot Pain in Relation to Ipsilateral and Contralateral Lower-Extremity Pain in a Population-Based Study

BACKGROUND

Clinical observations note that foot pain can be linked to contralateral pain at the knee or hip, yet we are unaware of any community-based studies that have investigated the sidedness of pain. Because clinic-based patient samples are often different from the general population, the purpose of this study was to determine whether knee or hip pain is more prevalent with contralateral foot pain than with ipsilateral foot pain in a population-based cohort.

METHODS

Framingham Foot Study participants (2002-2008) with information on foot, knee, and hip pain were included in this cross-sectional analysis. Foot pain was queried as pain, aching, or stiffness on most days. Using a manikin diagram, participants indicated whether they had experienced pain, aching, or stiffness at the hip or knee and specified the side of any reported pain. Sex-specific multinomial logistic regression was used to calculate odds ratios (ORs) and 95% confidence intervals for the association of foot pain with knee and hip pain, adjusting for age and body mass index.

RESULTS

In the 2,181 participants, the mean ± SD age was 64 ± 9 years; 56% were women, and the mean body mass index was 28.6. For men and women, bilateral foot pain was associated with increased odds of knee pain on any side (ORs = 2-3; P < .02). Men with foot pain were more likely to have ipsilateral hip pain (ORs = 2-4; P<.03), whereas women with bilateral foot pain were more likely to have hip pain on any side (OR = 2-3; P < .02).

CONCLUSIONS

Bilateral foot pain was associated with increased odds of knee and hip pain in men and women. For ipsilateral foot and hip pain, men had a stronger effect compared with women.

Relationship between foot pain, muscle strength and size: a systematic review

BACKGROUND

Foot pain is common and disabling and thought to be associated with muscle weakness. Understanding the relationship between pain and weakness may help identify effective treatment targets.

OBJECTIVES

To conduct a systematic review to evaluate the relationship between foot pain and foot muscle weakness, or muscle size as a proxy for weakness.

DATA SOURCES

Electronic databases and reference lists were searched for all years to April 2015.

ELIGIBILITY CRITERIA

Full-text articles were retrieved based on the question 'Does the study evaluate an association between foot pain and foot muscle weakness or size?'

DATA EXTRACTION AND SYNTHESIS

Two reviewers independently screened eligible studies, extracted data and completed a methodological rating.

RESULTS

Eight studies were identified evaluating the relationship between foot pain and foot muscle strength (n=6) or size (n=2). Four studies reported a significant relationship between pain and toe flexor force. One study reported a significant relationship between heel pain and reduced forefoot muscle size. One study reported an inconsistent association depending on measurement technique. One study reported no association between pain and hindfoot muscle size. One study reported no association between low to moderate pain and toe flexion force.

LIMITATIONS

Due to data heterogeneity, no data were pooled for meta-analysis.

CONCLUSION

There is evidence of a significant association between foot pain and muscle weakness when foot pain is of high intensity and primarily measured by toe flexion force. However there is inconsistent evidence that lower intensity foot pain is associated with other measures of foot muscle weakness or size. Systematic Research Registry ID reviewregistry166.

Are Pressure Time Integral and Cumulative Plantar Stress Related to First Metatarsophalangeal Joint Pain? Results From a Community-Based Study

OBJECTIVE

To examine the relationship between plantar stress over a step, cumulative plantar stress over a day, and first metatarsophalangeal (MTP) joint pain among older adults.

METHODS

Plantar stress and first MTP pain were assessed within the Multicenter Osteoarthritis Study. All included participants were asked if they had pain, aching, or stiffness at the first MTP joint on most days for the past 30 days. Pressure time integral (PTI) was quantified as participants walked on a pedobarograph, and mean steps per day were obtained using an accelerometer. Cumulative plantar stress was calculated as the product of regional PTI and mean steps per day. Quintiles of hallucal and second metatarsal PTI and cumulative plantar stress were generated. The relationship between predictors and the odds ratio of first MTP pain was assessed using a logistic regression model.

RESULTS

Feet in the quintile with the lowest hallux PTI had 2.14 times increased odds of first MTP pain (95% confidence interval [95% CI] 1.42-3.25, P < 0.01). Feet in the quintile with the lowest second metatarsal PTI had 1.50 times increased odds of first MTP pain (95% CI 1.01-2.23, P = 0.042). Cumulative plantar stress was unassociated with first MTP pain.

CONCLUSION

Lower PTI was modestly associated with increased prevalence of frequent first MTP pain at both the hallux and second metatarsal. Lower plantar loading may indicate the presence of an antalgic gait strategy and may reflect an attempt at pain avoidance. The lack of association with cumulative plantar stress may suggest that patients do not limit their walking as a pain-avoidance mechanism.

Fat Mass Is Associated with Foot Pain in Men: The Geelong Osteoporosis Study

OBJECTIVE

Foot pain is a common complaint in adults. Evidence suggests that body composition is involved in the development of foot pain. However, whether this is the case in men remains unclear because previous studies mainly examined women. The aim of this cross-sectional study was to determine the relationship between body composition and foot pain in men while accounting for important risk factors.

METHODS

Among 978 men (median age 60 yrs, range 24-98) from the Geelong Osteoporosis Study who participated in a followup study in 2006 to 2011, 796 provided responses to questions on health status and foot pain. Foot pain was determined using the Manchester Foot Pain and Disability Index, and body composition was measured using dual-energy x-ray absorptiometry.

RESULTS

Of the 796 respondents, 177 (22%) had foot pain. Risk factors for foot pain were age (OR 1.03, 95% CI 1.02-1.04), self-reported depression (OR 2.05, 95% CI 1.30-3.20), decreased mobility (OR 1.54, 95% CI 1.05-2.24), and lower education (OR 1.47, 95% CI 1.03-2.09). Foot pain was associated with body mass index (OR 1.05, 95% CI 1.00-1.10), fat mass (OR 1.02, 95% CI 1.03-1.05), and fat mass index (OR 1.08, 95% CI 1.01-1.15), but not fat-free mass (OR 1.01, 95% CI 0.98-1.04) or fat-free mass index (OR 1.05, 95% CI 0.95-1.15) after appropriate adjustments were made.

CONCLUSION

Fat mass is associated with foot pain in men. These findings complement those in studies that have mainly examined women, and provide further evidence for the relationship between obesity and foot pain.

Demographic and clinical factors associated with radiographic severity of first metatarsophalangeal joint osteoarthritis: cross-sectional findings from the Clinical Assessment Study of the Foot

OBJECTIVE

To explore demographic and clinical factors associated with radiographic severity of first metatarsophalangeal joint osteoarthritis (OA) (First MTPJ OA).

DESIGN

Adults aged ≥50 years registered with four general practices were mailed a Health Survey. Responders reporting foot pain within the last 12 months were invited to undergo a clinical assessment and weight-bearing dorso-plantar and lateral radiographs of both feet. Radiographic first MTPJ OA in the most severely affected foot was graded into four categories using a validated atlas. Differences in selected demographic and clinical factors were explored across the four radiographic severity subgroups using analysis of variance (ANOVA) and ordinal regression.

RESULTS

Clinical and radiographic data were available from 517 participants, categorised as having no (n = 105), mild (n = 228), moderate (n = 122) or severe (n = 62) first MTPJ OA. Increased radiographic severity was associated with older age and lower educational attainment. After adjusting for age, increased radiographic first MTPJ OA severity was significantly associated with an increased prevalence of dorsal hallux and first MTPJ pain, hallux valgus, first interphalangeal joint (IPJ) hyperextension, keratotic lesions on the dorsal aspect of the hallux and first MTPJ, decreased first MTPJ dorsiflexion, ankle/subtalar joint eversion and ankle joint dorsiflexion range of motion, and a trend towards a more pronated foot posture.

CONCLUSIONS

This cross-sectional study has identified several dose-response associations between radiographic severity of first MTPJ OA and a range of demographic and clinical factors. These findings highlight the progressive nature of first MTPJ OA and provide insights into the spectrum of presentation of the condition in clinical practice.

Correlates of foot pain severity in adults with hallux valgus: a cross-sectional study

Background

Hallux valgus (HV) is highly prevalent and associated with progressive first metatarsophalangeal joint subluxation and osteoarthritis. The link between structural HV deformity and foot pain is unclear. This study investigated possible explanatory factors surrounding foot pain in HV, including radiographic HV angle and signs of joint degeneration.

Methods

Participants were 60 adults (53 female) with HV aged 20 to 75 years. Participant demographics and a range of radiographic, clinical and functional measures were considered potential correlates of foot pain. Self-reported foot pain (visual analogue scales and a dichotomous definition) was considered the dependent variable. Multivariate modelling was used to determine which characteristics and measures explained pain, with univariate analyses first used to screen potential variables.

Results

Approximately 20 to 30% of the variance in foot pain associated with HV could be explained by patient characteristics such as poorer general health status, lower educational attainment and increased occupational physical activity levels, in combination with some dynamic physical characteristics such as hallux plantarflexion weakness and reduced force-time integral under the second metatarsal during gait. Neither increasing lateral deviation of the hallux (HV angle) nor presence of first metatarsophalangeal joint osteoarthritis was associated with foot pain.

Conclusions

This study shows that passive structural factors, including HV angle, do not appear to be significant correlates of foot pain intensity in HV. Our data demonstrate the importance of considering patient characteristics such as general health and physical activity levels when assessing foot pain associated with HV.

The association between body composition and foot structure and function: a systematic review

The aim of this systematic review was to investigate the relationship between body composition and foot structure and function. Six electronic databases (Ovid MEDLINE, Ovid EMBASE, Ovid AMED, CINAHL, Scopus and The Cochrane Library) and reference lists from relevant papers were searched on 2 September 2013. Sixteen papers that reported on the association between body composition and foot structure and function met our inclusion criteria and were reviewed. The evidence indicates that obesity is strongly associated with planus (low-arched) foot posture, pronated dynamic foot function and increased plantar pressures when walking. However, there is limited evidence to support an association between other body composition measures, such as fat mass, with foot structure or function.

Musculoskeletal conditions of the foot and ankle: assessments and treatment options

Musculoskeletal conditions of the foot and ankle are an important public health challenge due to their increasing incidence combined with their substantial negative impact on patients' quality of life. Non-pharmacological treatments serve as the first line of treatment and are frequently used for patients with musculoskeletal conditions of the foot and ankle. This review provides a summary of the assessments and non-invasive treatment options based upon available evidence. Recent studies show that individuals with foot and ankle pain have multiple co-existing impairments in alignment, motion, load distribution and muscle performance that may be evident in static and/or dynamic tasks. In addition, both clinical and epidemiological studies support the inter-dependence between the foot and proximal joints. For instance, aberrant foot structure has been linked to foot osteoarthritis (OA), as well as OA and pain at the knee and hip. Most recently, advances in motion capture technology and plantar load distribution measurement offer opportunities for precise dynamic assessments of the foot and ankle. In individuals with musculoskeletal conditions of the foot and ankle, the chief objectives of treatment are to afford pain relief, restore mechanics (alignment, motion and/or load distribution) and return the patient to their desired level of activity participation. Given that most patients present with multiple impairments, combinational therapies that target foot-specific as well as global impairments have shown promising results. In particular, in individuals with rheumatoid arthritis and other rheumatic diseases, comprehensive rehabilitation strategies including early detection, foot-based interventions (such as orthoses) and wellness-based approaches for physical activity and self-management have been successful. While significant improvements have been made in the last decade to the assessment and treatment of foot and ankle conditions, few randomised clinical trials specifically have investigated patients with foot or ankle conditions to provide global insights into this area. Consequently, current recommendations vary based upon the scope of studies presented in this review as well as the strength of studies. This review indicates a need for more in-depth investigations into the components of assessment and treatment options for foot and ankle musculoskeletal conditions.